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t <br /> GENERAL PROGRAM FILE New Change Edit (PROG3) revised 5/21/93 <br /> FACILITY ID # 64 FACILITY NAME <br /> RECORD ID # eoq '�3 PRIOR SWEEPS/COMP # <br /> DAIRY: Grade A Grade B Milk Dispenser Number of Containers in Multi-Head Unit <br /> _ FOOD: Restaurant Market Commissary Mobile Food Produce Stand Ice Plant <br /> Seating Capacity Sq Ft Market w/Food Prep: Y ! N <br /> Temporary Food Facility Special Food Event Vending Machines Number of Vending Units <br /> Food Vehicle Make License # Registration # Color <br /> HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA CE PBR <br /> HOUSING: Hotel/Motel No. of Units -Jail/Exempt Institution Housing Abatement <br /> Employee Housing No. of Employees Approx Dates of Occupancy - 1 / to <br /> LiQiiIr3`i:ASTE:'' reaper L''ehicle��`�P�rper Yard"` -Chemical`Toiiets- No` --Package TXCPlant <br /> T <br />- � MEDICAL WASTE: Primary Care Acute Care _Skilled Nursing — L-g-Generator Sm Generator•c�---�.�� <br /> u <br /> Storage•(2-10) Storage {11-50) Stor_ege,C` 50aTransfer Sta= Ltd�Ha ter 'Vet .Clinic *°' <br /> RECREATIONAL HEALTH: pool/Spa Number of Pools Out of Service Pool Natural Bathing Place <br /> SITE MITIGATION: Environ Assess UST/CAP Loc Haz Waste L,'� Haz Mat PPL <br /> Other Lead Agency Site Agency: RWQCB DTSC NPL Site RB/H20 Q Other <br /> SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac Ag Waste/Exempt Site <br /> SW Vehicle No. Dumpster No. Stationary Compactor Site <br /> VECTOR CONTROL: Poultry Farm Max Number of Birds Kennel <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT <br /> CONTACT 1 <br /> CONTACT 2 <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> # OF UNITS EPA 10 #: INSPECTION CODE <br /> BILLING and COMRLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that I have prepared this application and that the work to be performed will be done <br /> in accordance with all applicab AN JOAQUIN COUNTY Ordinance Codes and/or Standards a State and/or ederat taws. <br /> APPLICANT'S SIGNATURE / <br /> Title: Q�y�l ea" Date, /Z <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is avaitable and at the same time it is provided to me or my representative. <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/ / SUPV ��/ / ACCT !_- / UNIT CLK _/�f <br />